Undetectable for 1 year then went to 78 copies. CO Infection of Hep BOct 17, 2010

I have been on Atriplua since June of 2009. I went undetectable in Sept of 09. I was put on Atirpula since I am also Hep B positive and Pegulated Interferon wasnt working. In June of 2010 my Hep B was still at 600 Copies down from 600 Million copies and my HIV crept up to detecable 55 copies. My doctor added Entecravir to knock out the Hep B and as of last week I am now at 120 copies of Hep B, the problem is that my HIV level is still detectable. My doctor wants to stop the Entecrvir because it may be interfering with my Atripla and subsequently may cause a resistence. Do you think this is wise? Any advise would be helpful.

Thanks

Response from Dr. McGovern

I agree with your doctor that Atripla was a great selection for you. It is unfortunate that you did so well and now seemed to have hit a hard spot....

I would like to advise HBVdrug resistance testing so you can further determine what the problem may be. However, your level of virus is so low that I don't think this will be an option unless the viral load goes up further. This will require more HBV DNA monitoring. The same principle applies to HIV drug resistance testing.

Your doctor is probably concerned about Entecavir and its modest cross over activity against HIV. We usually only use that drug if someone's HIV is completely suppressed so I know why he is concerned.

This is a difficult situation and I would consider the following:

1. If you and your doctor do continue Entecavir, I would dose it at 1 mg instead of 0.5 mg. (You didn't mention your dosing but I would assume drug resistance to emtricitabine, one component of Atripla)

2. I would like to suggest an alternative approach that is somewhat novel, but I think would work in your situation.

Since you have low level HBV and HIV detection, a month's worth of pegylated interferon would suppress both viruses since this drug has dual activity. If you tolerated this drug in the past, I would consider this a good option since there is no risk of drug resistance. The activity of PEG against HIV was just recently published in Journal of Infectious Diseases and has been known since the APRICOT trial in HIV/HCV patients.

Once you have suppression of both viruses, you can start entecavir to keep your hepatitis B virus suppressed and then come off PEG when your doctor decides the timing is right. Whether you will need to switch your HIV regimen to something else in the future will be decided in good time...

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